Philip Craven - Breathlessness Flashcards
What are the RESPIRATORY differential diagnoses for shortness of breath?
- Asthma
- COPD
- Pulmonary fibrosis - Lung cancer
- Pulmonary embolism
- Pneumothorax
- Lower respiratory tract infection
What are the CARDIOVASCULAR differential diagnoses for shortness of breath?
- Congestive heart failure
- Heart attack
- Pulmonary oedema
- Valvular defects
- Acute coronary syndrome
- Anaemia
- Renal or liver failure
- Deconditioning - becoming unfit
What are PSYCHIATRIC differential diagnoses for shortness of breath?
- Anxiety
- Panic attacks
What are more SYSTEMIC differential diagnoses for shortness of breath?
- Being unfit
- Being an unhealthy weight (can lead to obesity hypoventilation syndrome if weight extreme)
- Smoking
- Muscular diseases eg. muscular dystrophy
- Postural conditions - kyphosis, scoliosis
What are the steps a doctor may take when a patient complains of breathlessness?
- Use the MRC breathlessness scale
- Ask questions about breathlessness
- Do some tests to help diagnose what is causing breathlessness
What is the MRC breathlessness scale?
Medical research council scale that shows what your breathlessness stops you doing and gives you a grade that describes you when you are at your best
What are some open questions that doctors may ask patients about breathlessness?
SOCRATES and family, drug and social history and ICE
What tests might doctors do to help diagnose the cause of breathlessness
- Use spirometer
- Respiration rate
- Chest X-ray
-ECG - Echocardiagram
- Chest auscultation
- BP and temp
- Blood test
- Psych questionnaire
etc.
What are some closed questions that doctors may ask patients about breathlessness?
- Is he waking up at night? (heart failure makes lying down worse due to fluid buildup)
- Chest pain
- Cough
- Colour of sputum (yellow/green - infection , pink + frothy - heart failure)
What is FVC?
FORCED VITAL CAPACITY
- Amount of air that can be forcibly exhaled from your lungs after taking the deepest breath possible
What is FEV1?
FORCED EXPIRATORY VOLUME IN 1 SECOND
- Maximum amount of air that the subject can forcibly expel during the first- second following maximal inhalation.
What is a normal FEV1/FVC ratio?
70-80%
Will FEV1 be higher lower or normal with restrictive lung diseases?
Normal if airways unaffected
Will FVC be higher lower or normal with restrictive lung diseases?
Lower as lung capacity is restricted
Will FEV1 be higher lower or normal with obstructive lung diseases?
Lower as air cannot be expelled quickly enough
Will FVC be higher lower or normal with obstructive lung diseases?
Normal even though airways are tighter they can get a normal amount of air in and out, just in a longer time frame
What are the possible causes of restrictive lung diseases?
- Scoliosis
- Interstitial lung disease
- Muscular dystrophy
- Obesity
- Sarcoidosis
What are the possible causes of obstructive lung diseases?
- COPD
- asthma
- bronchiectasis
- cystic fibrosis
What results are needed to confirm restrictive lung disease?
- FEV1/FVC ratio is normal/slightly higher
- FVC is lower
What results are needed to confirm obstructive lung disease?
- FEV1/FVC ratio IS LESS THAN 70% of predicted value
- FEV1 is less that 80% of predicted value
What is the pathophysiology of bronchitis?
- Chronic inflammation
- Caused by infection (normally)
- Mucuous gland hypertrophy
- Increase in goblet cells
- Narrower lumen
- Overproduction of mucus
- Phlegm cough (3 montyhs for 2 consectuctive years)
What is the pathophysiology of emphysema?
- Chronic inflammation
- Interconnections between alveoli gets broken down and results in increased sacs so smaller SA:V ratio therefore less efficient gas exchange
- No elastic recoil
- Hyperinflation
What are the signs on MrCraven’s xray indicating his emphysema?
- smaller + narrower heart
- Smaller diaphragm
- Gastric bubble
- Hyperexpansion
What are the signs of hyperinflation?
- More than 7 anterior ribs
- Flattening of the diaphragm
- Heart is small and narrow
What are some factors that help COPD?
- Smoking cessation
- Maintaining a healthy weight
- Keeping warm
- Good nutrition
- Pulmonary rehab programme
Name the types inhaled medications for COPD
Bronchodilator rescue therapy
- Beta -2- agonists and muscarinic antagonists
Inhaled corticosteroids
How do beta 2 agonists work?
- They interact with B2 receptors to activate coupling of G protein adenylcyclase.
- This leads to more cAMP –> pKA and this results in smooth mucle relaxation.
How do muscarinic antagonists work?
They block M3 receptors to prevent binding of Ach, indirectly stimulating smooth muscle relaxation via inhibition of bronchoconstriction.
How do inhaled corticosteroids work?
Anti inflammatory for airways
How are inhaled corticosteroids used?
NOT ALONE!
Numerous different drug combindations exist within a single inhaler - eg in combination with a long acting beta agonist
What are the treatments involved with smoking cessation?
- Abrupt quitting with a combination of drug treatment and behavioural support (NHS Stop Smoking Services)
- Nicotine replacement therapy, varenicline and bupropion hydrochloride
What is the most effective drug treatment for smoking cessation?
- Varenicline
- Long acting NRT and short acting NRT
How does NRT work?
Replaces nicotine and helps with unpleasant withdrawal symptoms
How does varenicline work?
Reduces cravings
Blocks the rewarding and reinforcing effects of smoking
How does bupropion hydrochloride work?
Has an affect on the parts of brain involved in addictive behaviours
